Health Care Homes (HCH)

Overview

Effective on or after July 1, 2010, the Health Care Homes (HCH) program, authorized by the Minnesota Legislature in 2008, allows qualified MHCP-enrolled providers to receive HCH reimbursement for the delivery of care coordination services to MHCP recipients who have complex and chronic medical conditions. For recipients enrolled in managed care organization (MCO), contact the MCO directly.

The development of the HCH initiative is a coordinated effort between the Minnesota Department of Health (MDH) and DHS and is driven by the Institute for Healthcare Improvement’s Triple Aim, an initiative to simultaneously achieve the following goals:

• Improve the individual experience of care

• Improve the health of the population

• Improve affordability by containing the per capita cost of providing care

Eligible Providers

Clinics and clinicians must meet a set of standards and criteria in order to be certified as a health care home in Minnesota. Use the MDH Health Care Homes certification process to become a certified Health Care Homes provider. To receive reimbursement for HCH services, providers must:

• Receive HCH certification from MDH

• Determine eligible HCH recipients

• Provide HCH services

• Claim HCH reimbursement once a month for each eligible recipient

Effective December 6, 2012, Health Care Home (HCH) clinics and providers must fax a copy of their MDH HCH certification or recertification letters to MHCP that include the following required information:

• HCH certification begin and end dates

• NPI/UMPI for each MHCP-enrolled clinic

• NPI/UMPI for each MHCP-enrolled individual provider

If the MDH HCH Certification – Report does not include the NPI/UMPI for the clinic or individual providers, you must provide this information using one of the following methods:

• Write the NPI/UMPI next to the clinician or clinic name

• Attach a separate list of the NPIs/UMPIs with the MDH HCH certification report

Fax copies of the MDH HCH Certification – Report that includes all required information to MHCP Provider Enrollment at 651-431-7462.

MHCP will not process requests without the NPI/UMPI and will add the certification dates to the provider record(s).

Before billing care coordination services S0281; access MN–ITS and verify the individual provider or clinic is listed on the Health Care Homes list accessible from the Provider Lists link in the left column.

Fax copies of certification including the NPI/UMPI to MHCP Provider Enrollment at 651-431-7462.

Eligible Recipients

Providers can assess the overall complexity of patients by grouping them into complexity tiers based on the number of major chronic condition groups that apply to them. MHCP recipients with one (1) or more major chronic condition are eligible for HCH. The Care Coordination Tier Assignment Tool (PDF) has been developed to support complexity assessments. Based on the above methodologies, recipients with major condition groups are scored as follows:

• Tier 1: 1-3 major condition groups

• Tier 2: 4-6 major condition groups

• Tier 3: 7-9 major condition groups

• Tier 4: 10 or more major condition groups

MHCP increases HCH reimbursement for care coordination when recipients (including their caregivers): recipients (or caregivers of dependent patients) having one of the following supplemental complexity factors:

• Need sign or spoken language interpreter services

• Have a serious and persistent mental illness

See the Care Coordination Tier Assignment Tool for how MHCP defines these factors. There will be a 15% increase for each factor; and a 30% increase when both apply. The corresponding procedure codes and modifiers for recipient tier level and the presence of supplemental factors are described below.

Care Delivery

• Care Coordination services are a team approach that engages the participant, the personal clinician or local trade area clinician, and other members of the health care home team to enhance the participant’s well-being by organizing timely access to resources and necessary care that results in continuity of care and builds trust

• Recipients must have at least one evaluation and management (E/M) visit per year with the HCH provider. See billing information below

Health Information Request (HIR) – enables clinicians to gather a more complete medical history for MHCP recipients. Use the automated HIR clinical tool to help improve care coordination, reduce duplication of services, and improve patient safety and quality of care.

Provider Alert – Practice-specific Provider Alert reports were generated for advanced primary care practices, for patients for whom a claim was submitted for an emergency room visit or hospital admission that happened in September, 2011 and was paid by the mid-October billing cycle. DHS Medicaid enrollment and claims data were used to create this report. DHS is piloting the Excel format and the content of the report, if of value to providers; the report could be distributed monthly.

Patients were assigned to the clinic they visited most frequently for Health Care Homes (HCH) care coordination (S0280/S0281) and Evaluation and Management (E&M) services, during the previous 24 months, ending on the last day of the report month. Each recipient of HCH services was assigned to the clinic associated with the most recently submitted care coordination (S0280/S0281) claim. All other patients were assigned to the clinic most frequently seen for E&M visits in the 24-month observation period. If the patient had equal numbers of E&M visits to multiple clinics, the recipient was assigned to the clinic visited most recently.

This report includes information related to coordination and continuity of care including:

• Hospitalizations and emergency room visits

• Health care home provider and majority source of care provider

• Probability of hospitalization in the next 12 months

• Health care home claim status

• HCH TierNeed for interpreter

• Mental health conditions

This message should be directed to the health care home team member(s) who assess the patient registry to determine care coordination need. The Provider Alert file can be found in your MN–ITS Mailbox under Miscellaneous Received, in File Type: ProviderFile. Refer to the Provider Alert Reference Guide for the reports data descriptions.

Billing

To claim care coordination payment from MHCP for fee-for-service recipients

1. Document all care coordination services provided and justification for complexity tier assignment in the recipient’s medical record

2. Use the 837P electronic claim transaction to submit all claims

3. A single date of service represents the entire month. Bill on one claim transaction, enter 1 unit of Initial Care Coordination planning code S0280 for the first month. Enter Maintenance Care Coordination Planning code S0281 for each additional month. Bill the procedure code once a month with:

• Modifier U1: Tier 1

• Modifier TF: Tier 2

• Modifier U2: Tier 3

• Modifier TG: Tier 4

• And, if necessary

• Modifier U3: If primary language is Non-English

• Modifier U4: If Severe and Persistent Mental Illness

Recipients must have an E/M visit with the care coordination provider within the last 12 months from the care coordination procedure code date of service to be eligible for reimbursement. The appropriate E/M procedure code can occur on a different date of service and be billed separately from the care coordination procedure code. E/M visit procedure codes considered are 99201-99205, 99211-99215, 99324-99328, 99334-99337, 99339, 99340, 99341-99345, 99347-99350, 99381-99387 and 99391-99397.

Reimbursement is the lower of the submitted charge or when the rendering enrolled provider is either a physician or nurse practitioner, per these tiers:

Physician

Nurse practitioner or physician assistant

Tier 1: $ 10.14

Tier 1: $ 9.81

Tier 2: $ 20.27

Tier 2: $ 19.61

Tier 3: $ 40.54

Tier 3: $ 39.22

Tier 4: $ 60.81

Tier 4: $ 58.83

HCH reimbursement is dependent on verification that both the pay-to provider and treating provider are eligible for HCH and that the recipient is enrolled.